The Insurance Company Giveth, the Insurance Company Taketh Away

As you know, being in ART-limbo has been driving me steadily insane. Last week, J and I decided to buy a little piece of sanity—we are going start paying out-of-pocket for at least some of the drugs that might (emphasis *might*) kick-start J’s sperm production. We figure that even if insurance eventually denies us coverage, we would probably pay for a couple of months of treatment, just to see if it was going to do any good. So we decided to pay for a few weeks while we waited to hear back on our most recent appeal.

Last Wednesday I faxed in J’s prescriptions to Schraft’s (the cheapest specialty pharmacy out there), along with a note saying that he would call to work out ordering and delivery. The next morning, I got a call from Schraft’s with a question for the doctor (they assumed that I was the nurse). Once I gave them the doctor information, I also gave them J’s information—phone numbers, e-mail, date of birth, etc. When she asked about insurance I told her not to worry about it. “We’re in a protracted battle with the insurance company right now, so we don’t have any coverage,” I explained. She suggested that I give her the information anyway, just so his files would be complete.

That night, J picked me up at the train station with “good news.” His prescriptions were covered! “Not possible,” I said. Our most recent appeal—the previous one having been rejected by the asshole HMO because we had the wrong pre-auth number on it—was only a day old.

“That’s what I told them,” he said, “but they told me it had gone through and I owed a $50 copay.”

“So you filled the whole thing? All three months?” I asked, incredulous.

“Yup.” He grinned. “They actually called back to tell me it was going to be a $50 copay per month. I was like, ‘okay!’”

“I don’t believe it,” I said, “They’re gonna call back and say it was a mistake. Tonight.”

“Probably,” he agreed.

We went into the house and I went back into the bedroom to change my clothes. The phone rang. Our caller ID—which we’ve never been able to take off of “audio”—announced “Call from . . . Schrafts.” We looked at each other. “Well, it was a nice 15 minutes,” I offered.

From what J was saying on the phone, it was obvious what was happening. “Not covered? . . . We’ve reached our ‘cap’? . . . What exactly does that mean?” After a minute, he pulled out his credit card and ordered a three-week supply. We both knew that there was no “cap” to our coverage; we just weren’t covered. But whatever.

And in a normal world, that would be that. But this was no normal world. Because 15 minutes later the phone rang again. “Call from . . . Schrafts,” announced our caller ID in its creepy computer monotone.

“What the fuck?” I muttered, handing the phone off to him.

A minute later, he was off the phone again, total confusion on his face. “That was the pharmacist. She was calling to tell me that the person who called earlier was wrong and we haven’t exceeded our cap.”

“So we’re covered?”

“That’s what they say.”

“And you filled the entire thing?”

“Yup.”

We waited all evening for the call that never came. The next day the drugs were delivered to our RE. Today J picked them up.

I don’t think Schraft’s come after us for this when our HMO realizes its mistake, can they? We were totally up front with them about this.

Score one for the little guy. (Not that J’s little, or anything.)